For Health Care Access, Place Matters

8:17 November 15, 2011

When Jaya Aysola was working to build patient-centered community health practices as a practicing physician in New Orleans in the aftermath of Hurricane Katrina, she realized that simply delivering resources to under-served patients wasn’t enough.

A new clinic or a mobile health van visiting the heart of a neighborhood was a good start, but was not sufficient to build the kind of relationships between caregivers and community members that creates a patient- and family-centered medical home, a high-quality primary care model that is being advocated in many policy initiatives, including the Affordable Care Act of 2010. The characteristics of medical homes—strong relationships between health care teams and their patients, a focus on listening and responding to the patient and family’s needs and including patients and families as partners in medical care—are associated with improved health outcomes.

Many of the techniques Aysola’s teams employed to build community engagement were not part of the standard prescription for building a medical home. The standard model failed to measure factors such as cultural effectiveness and effective communication from the patients’ point of view. And the model didn’t take into account the sometimes stark differences in the quality of life between neighborhoods. She wondered how important these factors were to providing a medical home that was truly patient and family-centered.

The presence in a neighborhood of houses in a state of disrepair, like this Lower 9th Ward home, still battered and broken nearly four years after Hurricane Katrina, may limit access to high-quality medical care. Photo courtesy Jaya Aysola.

Aysola, a research fellow in the HMS Department of Health Care Policy and in general medicine and primary care at Brigham and Women’s Hospital, is now lead author on a study that provides some surprising insight into the vital role of neighborhood characteristics in children’s access to medical homes.

“Place does indeed matter,” Aysola said. “The social and physical context in which a child resides influences their ability to have access to this high-quality type of care, and it is actually more strongly associated than individual factors such as family income or race.”

The study, published Nov. 8 in Health Affairs, was coauthored by E. John Orav, associate professor of medicine (biostatistics) at HMS and senior author John Ayanian, HMS professor of health care policy and medicine.

The researchers examined the relationship between neighborhood characteristics—cohesion, safety, physical environment—and whether children received care from a patient-centered medical home.

While 93 percent of respondents in a nationally representative survey of parents and guardians said their children had access to primary care services, only 58 percent met the criteria for having a medical home. The study focused on children because the concept of the medical home was initially developed within pediatrics.

Children who were non-Hispanic whites, those from higher income households and those who were privately insured were more likely than their counterparts to have access to a medical home, but the study revealed that factors such as neighborhood safety and community cohesiveness accounted for much of the socioeconomic and racial disparities.

For example, when rates are adjusted for socioeconomic and demographic variables, 50.1 percent of respondents who say they lived in areas with low neighborhood cohesiveness have access to a medical home, while 63.3 percent in very cohesive neighborhoods have such access.

“This study underscores the important role of neighborhood factors as social determinants of children’s access to patient-centered primary care,” Ayanian noted.

Significant geographic and economic disparities exist in access to medical homes, but until now contributing factors had not been scrutinized. Aysola says it will be important for teams who are trying to implement the medical home model to understand what factors may limit uptake, adding that many factors—such as having on-site interpreters and building relationships with other community organizations including schools and churches—have been shown to increase access to medical homes.

The researchers note that understanding patient access to medical care is an emerging science. These results suggest that clinicians and policy makers need to take into account the nuances of the complex social, cultural and physical environments in which their patients live.

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